NUTRITION IN THE LIFESPAN # 4C

1. NUTRITION IN THE LIFESPAN # 4C Lalita Bhattacharjee Nutritionist National Food Policy Capacity Strengthening Programme Food and Agriculture Organization of the United Nations Bangladesh Presented on 2 July 2011 at the Training Workshop on “Food Security Concepts, Basic Facts and Measurement Issues” 25 June to 7 July 2011

2. OUTLINE • Introduction • Nutrition through the life stages • Dietary energy and nutritional requirements in: • Infancy - birth to 1 year • Childhood and adolescence • Pregnancy and lactation • Intergenerational effects • Diet, energy and nutritional requirements in adulthood • Nutrition during ageing and the elderly • Operational Plan Indicators • Life cycle approach • Conclusion

3. Introduction • Diets in all cultural variety define to a large extent people’s health, growth and development • Advances in research, expansion of knowledge in prevention and control of chronic diseases • Return to the concept of basic life course – continuity of human life from fetus to old age • Need to address both undernutrition and overnutrition

4. Nutrition vs Food Security • Nutritional status is internationally recognized as an indicator of national development • Nutrition is both an input and an output/come of the development process • A well-nourished population is essential for productive work force and development • people need food, health and care to be well-nourished • Two processes: • on the one hand food security policies • on the other sustainable livelihoods, right to food and nutrition policies • …with different partners • The food, agriculture and health sectors is responsible for food and nutrition security

5. MATERNAL, CHILD AND HOUSEHOLD NUTRITION

7. Fetal development and maternal environment : Relevant factors • Intra uterine growth retardation (IUGR) • Premature delivery of a normal growth for gestational age fetus • Overnutrition in utero • Intergenerational factors

9. Nutrition through the life stages : Infancy – Birth to 1 year • Dietary, energy and nutritional requirements • All neonates typically lose some weight after birth • Pre term infants are born with more extra cellular water than term infants and thus lose more weight than term infants • Post natal loss should not be excessive. • Loss of 15-20% of birth weight can lead to dehydration – inadequate fluid intake or tissue wasting from poor energy intake

10. Child growth at different ages

11. Nutrition through the life stages : Infancy – Birth to 1 year What defines Infancy? The first year of life. Why are the nutrient needs of an infant so high? Infants grow at accelerated rate: double birth weight by 6 months; triples by 12 months of age

12. Relationship of Breastfeeding Practices with Mortality of (0-12) months children in Bangladesh Source:Arifeen et al, 2001

13. The new era of Breastfeeding Growth chart of 21 century New International Child Growth Standards for infants and young children released on 27 April 2006 ⇛ A community based study “The Multicentre Growth Reference Study (MGRS)’’ undertaken by WHO & United Nations University ⇛ More than 8000 children followed after every 3 months from Brazil, Ghana, India, Norway, Oman and USA

15. What are the nutrient needs of an infant and why are they so high? Monitoring infant growth: Infants not receiving adequate nutrition may have difficulty reaching milestones Failure to thrive (FTT):delayed in physical growth or size or does not gain enough weight Growth chartstrack physical development. Head circumference, length, weight, and weight for length measures are used to assess growth

16. What are the nutrient needs of an infant and why are they so high? Infants have specific calorie, iron, and other nutrient needs. 108 calories/kg of body weight for first 6 months 9.1 g protein/day first 6 months, 11 g/day second 6 months Fat should not be limited. Vitamin K injection needed due to sterile gut Iron-enriched cereals/home based foods should be introduced at 6 months.

17. Infant Nutrition: Solid Foods Complementary foods Not recommended to give any solid foods before 6 months When to begin About 6 months of age Iron and zinc stores depleted Look for physical signs Loss of extrusion reflex Nutrient-dense foods

19. When Are Solid Foods Safe? Solid foods should be introduced gradually to make sure child isn’t allergic or intolerant One new food per week Rice cereal is great first food: least allergy-causing Other grains, then vegetables, fruits over a period of months Homemade or store-bought baby food? Homemade is cheaper, but can also find high-quality store-bought foods without added sugar, salt, preservatives

21. The Global Strategy of IYCF • Implementation of comprehensive policies by the Government • Full support for two years of breastfeeding or more • Promotion of timely, adequate, safe and appropriate complementary feeding • Guidance on IYCF in especially difficult circumstances, • Legislation or suitable measures giving effect to the International Code

22. Percent children underweight1980-2007

23. Nutritional status of children U5

24. Nutrition and Poverty: Prevalence of Underweight by Wealth Quintiles (Children <5 yrs, below -2SD) Is Malnutrition in South Asia Really Worse than in Africa?

25. Nutritional status of children by wealth quintile in Bangladesh

26. Energy requirements at different ages

30. Childhood and adolescence • Association between low growth in childhood and increased risk of CHD, irrespective of size at birth • Postnatal factors shaping disease risk • Growth rates of infants in Bangladesh (most of whom had chronic IUUN and were breast fed, were similar to growth rates of breast fed infants in industrialized countries • Catch up growth was limited and weight at 1 yr was a function of birth weight

31. Childhood and adolescence • LBW babies have characteristic poor muscle but high fat preservation ( so called thin fat babies) • This phenotype persists throughout post natal life and is associated with increased central adiposity in childhood that is linked to ↑ risk of raised BP and disease • Association between LBW and high BP and BMI – importance of weight gain after birth • Relative weight in adulthood and weight gain associated with ↑ risk of cancers • Height serves partly as an indicator of socio economic and nutritional status in childhood (energy and protein intake)

32. Adolescence: Physical changes • Secondary sexual characteristics emerge, with onset of menarche (periods) in girls and semenarche (production of semen) in boys • Physical developments are accompanied by marked changes in psychological and emotional make up, characteristic of ‘teenage’ behaviour • Adolescence begins approx 2 years earlier in girls than boys, with acceleration of growth of muscle in boys and deposition of adipose tissue in girls • According to WHO, 10 to 18 y is the period of adolescence

33. Adolescence: Physical changes • Adolescent boys experience rapid muscular growth and engage in more physical activities than girls so they need more energy foods • Adolescent girls, because of menstruation, need more iron than boys • Iron is essential for building and maintaining blood supplies ad giving the blood its red colour • Girls should take more iron rich foods such as liver, egg yolk, lean meat, green leafy vegetables, dried beans, dried fruits and unpolished rice and whole wheat

34. Iron requirements during adolescence

36. Adolescence : Critical aspects • Development of risk factors • Tracking of risk factors (in terms of prevention) • Development of healthy/unhealthy habits that tend to stay throughout life (physical inactivity) • Older adolescents (habitual alcohol, tobacco use associated with risks of ↑ BP and related risks • Syndrome X ( physiological disturbances, hyper insulinemia, impaired GT, HT, ↑ TG and ↓ HDL

37. Weight gain during pregnancy • Weight gain during pregnancy is an indicator of nutritional status of pregnant women • A weight gain of 11 -13 kg during the pregnancy term is ideal • According to various studies, weight gain during pregnancy in Bangladeshi mothers is only 7-9 kg indicative of poor nutritional status of the mother and poor growth of the fetus • The fetus is born with LBW ( < 2.5kg) • Over a third (36%) of babies in Bangladesh are born with LBW

38. Additional energy cost of pregnancy with gestational weight gain of 12 kg NIN/ICMR (2010) Nutrient requirements and RDA for Indians

39. LACTATION • Lactation is the period when the mother feeds her baby through the breast. • On an average 600-800 ml/d milk is produced by a nursing mother • Approximately 1kcal of energy is needed to produce 1 ml of milk • Malnutrition during pregnancy is likely to continue after birth of the baby if the mother is poorly nourished; a malnourished mother cannot breast her baby adequately • Malnutrition affects the volume of milk produced if not its quality

40. Energy requirements at different ages

41. Women of reproductive age: • The reproductive age in Bangladeshi mothers is considered as 15 to 44 years • CED in women of reproductive age is measured by height and BMI • Height < 145 cm and BMI < 18.5 kg/m² is indicative of chronic CED

43. The “Window of Opportunity” for Improving Nutrition is very small…pre-pregnancy until 18-24 months of age Repositioning Nutrition, 2006

44. New Evidence shows the “window of opportunity” may be even smaller than we had anticipated…with a larger part of the damage happening before birth… Mean height for age z-scores by age relative to the new WHO reference By region (0-59 months) Source: Victora CG, et al. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics, 2010 (Feb 15 Epub ahead of print)

45. Women’s status and reductions in child undernutrition Contributions to reductions in child malnutrition, 1970-95 Source: Smith and Haddad 2000

46. Adulthood : Risk factors • To what extent risk factors continue to influence development of CD • To what extent will modifying such risk factors make a difference in the emergence of disease • What is the role of risk factor reduction and modification in secondary prevention and the treatment of those with disease • Adult phase of life –disease expressed, critical time for preventive reduction of risk factors and increasing effective treatment

47. Ageing and older people :Critical aspects • Most chronic diseases will be manifested in later stages of life • Absolute benefits in changing risk factors and adopting health promoting behaviours (exercise and healthy diets) • Maximize health by avoiding /delaying preventable disability • Along with societal and disease transitions, major demographic shifts • Older people defined above 60 y • Average life expectancy increased from middle of last century • Majority of elderly will be living in the developing world

48. DETERMINE : CHECK LIST • Disease • Eating poorly • Tooth loss/Mouth pain • Economic hardship • Reduced social contact • Multiple medicines • Involuntary weight loss/gain • Needs assistance in self care • Elder years above age 80

49. Elderly should have a nutrient rich diet to keep fit and active • Reduced need for calories • More prone to disease due to lowered food intake, physical activity and resistance to infection • Good food habits and regular exercise minimize the ill effects of ageing • Need for more calcium, iron, zinc, VA and anti oxidants to prevent age related diseases Note: Variety of nutrient rich foods, match food intake with physical activity, eat food in many divided portions/d, avoid fried, salty and spicy foods and exercise regularly

50. Policy implications from the new WHO growth references ++ recent evidence • Confirms importance of first 2 years of life as a critical window within which child growth is most sensitive to environmentally modifiable factors • Monitoring length/height (in addition to weight) seems essential because faltering patterns are clearly different for HAZ and WAZ, and short stature is associated with deleterious long-term outcomes • Reveal a much greater problem of undernutrition during the first 6 months of life than previously understood (shorter “window of opportunity”) with possibly even higher levels of intrauterine growth retardation emphasizing the need for even greater need for prenatal and early-life interventions, including preventing low birth weight and promoting appropriate infant feeding practices • Suggests that BMI gain after 6 months of age increases adiposity but not height at 5years – hence potentially negative implications for NCDs in adulthood